An Intersectionality-Based Policy Analysis Framework

Transcription

1 Author An Intersectionality-Based Policy Analysis Framework Edited by Olena Hankivsky

2 SUGGESTED CITATION: Hankivsky, O. (Ed.). (2012). An Intersectionality-Based Policy Analysis Framework. Vancouver, BC: Institute for Intersectionality Research and Policy, Simon Fraser University. This publication is also available online at CONTACT INFORMATION: Institute for Intersectionality Research and Policy Simon Fraser University, Harbour Centre Campus Room 3274, 515 West Hastings Street Vancouver, B.C. Canada V6B 5K3 Tel: (778) Library and Archives Canada Cataloguing in Publication Hankivsky, Olena, An Intersectionality-Based Policy Analysis Framework / Olena Hankivsky (Ed.). Includes bibliographical references. ISBN Copyright 2012 by Institute for Intersectionality Research and Policy. All rights reserved. No part of this framework may be reproduced by any means without the written permission of the publisher, except by a reviewer, who may use brief excerpts in a review. The Institute for Intersectionality Research and Policy (IIRP) enables and supports innovative groupings of scholars including interdisciplinary, intersectoral collaborations which foster the generation, application, and policy translation of intersectionality informed research. Please go to for more information.

3 An Intersectionality-Based Policy Analysis Framework Edited by Olena Hankivsky

4 Acknowledgements The authors would like to thank the anonymous reviewers for their thoughtful and insightful comments on this collection. We would also like to acknowledge and thank participants of the Spring 2011 hosted by the Institute for Intersectionality Research and Policy in Mission, BC for their initial feedback on the IBPA framework. The development and production of this collection was made possible by funding provided through Olena Hankivsky s Michael Smith Foundation for Health Research Senior Scholar Award and CIHR IGH Mid-Career Research Chair in New Perspectives on Sex/Gender, Diversity and Health Reform in Canada. We would also like to acknowledge funding from the CIHR IGH dissemination grant program.

5 Table of Contents Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis...7 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte Intersectionality-Based Policy Analysis...33 Olena Hankivsky, Daniel Grace, Gemma Hunting, Olivier Ferlatte, Natalie Clark, Alycia Fridkin, Melissa Giesbrecht, Sarah Rudrum, and Tarya Laviolette Policy Case Studies An Intersectional Critical Discourse Analysis of Maternity Care Policy Recommendations in British Columbia...47 Sarah Rudrum Intersectionality and the Place of Palliative Care Policy in British Columbia, Canada...69 Melissa Giesbrecht A Call for a Policy Paradigm Shift: An Intersectionality-Based Analysis of FASD Policy...93 Gemma Hunting Decolonizing Policy Processes: An Intersectionality-Based Policy Analysis of Policy Processes Surrounding the Kelowna Accord Alycia Fridkin Perseverance, Determination and Resistance: An Indigenous Intersectional-Based Policy Analysis of Violence in the Lives of Indigenous Girls Natalie Clark Reconceiving the Problem in HIV Prevention: HIV Testing Technologies and the Criminalization of HIV Non-Disclosure Daniel Grace Are There Enough Gay Dollars? An Intersectionality-Based Policy Analysis of HIV Prevention Funding for Gay Men in British Columbia, Canada Olivier Ferlatte

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7 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte As has been recognized elsewhere, the public policy world is in a constant state of flux (Orsini & Smith, 2007). Political, economic, environmental and health crises and events are creating new kinds of policy problems and challenges at international and national levels. Moreover, there is growing awareness that although policy alone cannot transform society, it does have an important but not yet fully understood role in the creation of more just and equitable societies (Bryant, Raphael, Schrecker, & Labonte, 2011; Hankivsky & Cormier, 2011; Ingram & Schneider, 2006; Stone, 2001). In light of such developments, existing policy tool kits need to be re-examined to evaluate the adequacy of information currently being generated to inform policy and, importantly, to more fully explore and determine what policy analysis is supposed to achieve (Orsini & Smith, 2007). In the field of health, calls have been made for policy acumen (Jones & Salmon, 2001) to deal with increasingly complex environments that shape and influence health. Although there is no shortage of approaches to health policy analysis (e.g., Collins, 2005; Dunn, 1981; Portney, 1986) there is little attention to meaty dialogue around the kinds of theoretical frameworks that can improve policy analyses (Abelson et al., 2008) so that a broader and more accurate base of information about what makes people healthy or alternatively unhealthy can be generated. The purpose of this introductory chapter is to advance this dialogue by critically examining existing approaches to health policy analysis, including their theoretical and practical utility, and, in the process, highlighting what important issues they fail to adequately confront in relation to health inequities. We then move on to make the case for why the theory of intersectionality holds so much promise in constructing an improved method for policy analysis that can generate knowledge necessary for achieving more inclusive, just, effective and efficient health policies. Arguably, intersectionality can significantly advance the operationalization of equity in public policy. 7

8 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis The chapter begins with a brief overview of public policy, health policy and a number of select approaches to health policy analysis, including sex and gender based analysis and health equity impact assessment tools, which, to date, represent the most promising state of the art tools for determining the distributional effects of health policy. Our investigation reveals that despite progress made to date, there is still much work to be done to better understand how policy affects the diversity of populations, including precisely identifying who is benefiting and who is excluded from health policy goals, priorities and related resource allocation. In this collection, we follow Waldegrave (2009) in arguing that: We need to deconstruct the industries of... policy making from the perspectives of culture, gender, and socioeconomic status and enquire as to the reasons for their hegemony and practice. Are they... achieving equity? Do they enable the goals of social inclusion and well-being to be reached? Do they respect the breadth of citizenship in a country, and do they enhance or hinder the inspirations of all citizens? (p. 97) Our central argument is that in drawing on the theory of intersectionality we can build on and improve existing equity focused tools, and specifically, health equity impact assessment tools. Our aim is lay the groundwork for an Intersectionality-Based Policy Analysis (IBPA) Framework that we present in detail in the next chapter (Hankivsky et al., 2012). The IBPA Framework facilitates the asking of questions that can capture the most important and relevant information about decision-making priorities, processes and policy outcomes. In advancing a case for intersectionality in policy analysis our goal is to bring about a paradigm shift that foregrounds the complex contexts and root causes of health and social problems. Extending beyond gender-specific and social determinants frameworks, intersectionality focuses attention on a variety of multi-level interacting social locations, forces, factors and power structures that shape and influence human life. In the context of health broadly conceived the lens of intersectionality can better illuminate how policy constructs citizens relative power and privileges vis-à-vis their status, health and well-being. As Bacchi and Eveline (2010) put it, policies do not simply impact on people; they create people (p. 52), including their social locations, and access to power and resources. 8

9 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte What is Public Policy? What is Health Policy? Public policy can be understood as a guide to action, a plan, a framework, [or] a course of action or inaction designed to deal with problems (Pal, 2001, p. 5). In general, public policy is seen as an output from governments, namely what public officials, within government, and by extension the citizens they represent, choose to do or not to do about public problems (Kraft & Furlong, 2009, p. 5). But public policy is not only an observed phenomenon of what governments do or choose not to do. It also has a normative component because it raises questions about what governments ought or ought not to do (Simon, 2009). Public policy thus reflects the type of social contract that is envisioned for society, including the written and unwritten agreement that we continually rewrite stating what we want to do for each other collectively and what we want other members of society to do for us as individuals (Simon, 2009, pp. 1-2). Public policy is largely driven by arguments about whether something is a problem, whether it is a solvable problem, what the potential solutions are, what the costs of those solutions are, and whether the solutions will be wholly or more likely, partially effective (Birkland, 2011, p. 10). While it is ultimately governments responsibility to create policies, the ideas that underpin these policies often emerge from outside government, including through interactions between government and non-governmental actors (Birkland, 2011). Indeed, civil society often plays a critical role in shaping policies, especially when governments try to manage public outcries or public dissatisfactions with current societal practices or the government itself (Varcoe, Pauly, & Laliberté, 2011). Thus the development of policies is often dependent on many factors, which may include, but are not limited to: the public interest, the effectiveness of the policy, cost, and whether a policy is socially acceptable and politically viable (Dye, 2010; Kraft & Furlong, 2009). Although it is typically thought that policy is operationalized through constitutions, statutes, regulation, case law and legislation, it is also important to recognize that policies reveal themselves in different ways, including through texts, practices, symbols and discourses that define and deliver values including goods and services as well as regulation, income, status and other positively or negatively valued attributes (Schneider & Ingram, 1997, p. 2). Public policy is significant because it is a means by which societies regulate themselves and attempt to channel human behaviour (Birkland, 2011; Kraft & Furlong, 2009; Schneider & Ingram, 1997). In this way policies have profound and pervasive effects on individuals and populations. As Torjman (2005) put it: We literally eat, drink and breathe public policy (p. 1). 9

10 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis Yet each specific policy sector, including health, is also unique. Health policy refers to decisions, plans and actions undertaken to achieve specific health care goals within a society (World Health Organization [WHO], 2010). According to Coveny (2010), three features make health policy different from other areas: 1) the influence of the medical profession in health care in general; 2) the monopolistic nature of health care systems; and 3) the fact that health policy involves life-and-death decisions, which are unparalleled in other areas of public and social policy (p. 515). In this project, however, we move beyond the confines of narrowly defined health policy to embrace the concept of healthy public policy, that is, public policies, outside the formal health sector, that have an impact on health, such as education, transportation, and fiscal policies (National Collaborating Centre for Healthy Public Policy, 2007, para. 2). Health Policy Analysis Analyzing policy is of crucial importance in modern complex societies because public policy is so vast, public problems are sophisticated and often inter-connected, and public policies have tremendous social, economic, and political implications (Simon, 2009, p. 59). The task, however, is complicated because good policy analysis, as has been widely argued, is both an art and a craft (Dye, 2010; Kraft & Furlong, 2009). As Dye (2010) elaborates: It is an art because it requires insight, creativity, and imagination in identifying societal problems and describing them, in devising public policies that might alleviate them, and then in finding out whether these policies end up making things better or worse. It is a craft because these tasks usually require some knowledge of economics, political science, public administration, sociology, law, and statistics. (p. 8) Health policy analysis (HPA) has been defined in various ways, including: a multidisciplinary approach to public policy that aims to explain the interaction between institutions, interests and ideas in the policy process (Walt et al., 2008, p. 308); an interdisciplinary field that investigates how health policy is made, what it is, what it might become, and what its effects are (Abelson & Giacomini, 2003, para. 2); and as the generic name for a range of techniques and tools to study the characteristics of established policies, how the policies came to be and what their consequences are (Collins, 2005, pp ). In general, HPAs are intended to allow policy actors to learn from policy failures and successes so as to inform the future design and implementation of policies (Gilson & Raphaely, 2008; Walt et al., 2008). 10

11 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte In this collection, we define health policy analysis as a social, political and intellectual endeavor carried out by diverse stakeholders, including university-based researchers, bureaucrats, health professions and other policy actors, such as community-based groups and organizations. HPAs often take an interdisciplinary approach to understanding the (a) production process of health policy (how it is made), (b) the product of health policy (what it is), the (c) the power of health policy (what effects it has in the everyday world), and (d) normative claims regarding future policy directions (what policy should look like). This broad definition of health policy analysis involves a concern with examining complex power-laden policy processes, investigating policy content, determining policy outcomes across the population, and identifying effective and inclusive policy options (see Abelson & Giacomini, 2003; Bardach, 2000; Ham, 1991; Walt, 1994). Analysis of Approaches to Date According to Walt et al. (2008) little attention has been paid to how to do health policy analysis, including what research designs, theories or methods might best inform such analyses (p. 308). Techniques for conducting HPAs to date range from simplified stepby-step linear models specifically tailored for conducting HPAs (Bardach, 2000; Collins, 2005) to more specialized tools largely organized around conceptions of the policy making process and/or problem definition (Bacchi, 1999), or focused on specific questions about the nature and types of policy, the process of making policies, and the effects of policy in the everyday world (Abelson & Giacomini, 2003). In general, HPAs have prioritized efficiency, effectiveness and political feasibility of policy, while assuming that public policies are neutral and benefit all citizens equally. However, policy processes are imbued by power and privilege, and thus have differential effects across populations (Birkland, 2011). There is growing recognition that governments need to be measured by their ability to deliver policy that can advance social justice and equity (Marmot, 2012) correct power imbalances, and address damaging stereotypes and social constructions among stakeholders (Ingram & Schneider, 2006, p. 184). Moreover, there is increasing pressure to improve the measurement, analysis and monitoring of policies in order to better capture their differential and distributional health impacts on diverse populations (Braveman, 2003; Commission on Social Determinants of Health, 2008; Global Equity Gauge Alliance et al., 2008). Although the effects of a broad-based policy may be associated with an improvement in overall population health, such traditional approaches often make use of static conceptions of sub-groups and concomitant risk factors. As a result they may not effect meaningful change in the health of those situated at intersecting axes of disadvantage 11

12 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis (Brëdstrom, 2006; Eek et al., 2010; Fetene & Dimitriadis, 2010; Fiske & Browne, 2008; Greaves et al., 2006; Paterson, 2010; Thomson, Murtagh, & Khaw, 2005). Health and health related policies need to be closely interrogated to determine how they signal who is important and who is not, specifically through how different publics are involved, positioned and affected. Such policies need to be evaluated in terms of how different perspectives of problems are recognized as legitimate or ignored, and whether certain populations experience burdens or benefits from policies, including the effects of policy on the health and well-being of populations. Arguably such lines of questioning are especially pressing and relevant given the recent global financial crisis and economic slowdown, which have created budgetary constraints and placed pressure on policy actors to undertake broad policy reforms that exacerbate social and health inequities (Hacker & Pierson, 2010; Navaro & Muntaner, 2004; Neysmith, Bezanson, & O Connell, 2005; Unger, De Paepe, Ghilbert, Soors, & Green, 2006). While many international jurisdictions have worked to develop equity-focused policy analysis tools, in Canada there are two specific types of analysis that have emerged as best practices for capturing the differential effects of policy on the population: (1) sex and gender based analysis (SGBA), which is informed by gender theories of inequity; and (2) health and health equity impact assessments (HIAs/HEIAs), which are underpinned by social determinants of health frameworks. Each of these has been applied to various stages of the policy cycle, but has been considered most effective when applied prospectively to inform the development of policy and to ensure that analysis of policy effects are determined prior to any implementation. And while each has made important contributions to understanding how policy actually affects differently situated populations, a closer examination illustrates shortcomings that are directly linked to their theoretical underpinnings and highlights the need and importance of an intersectional perspective for effective health policy analysis. Sex and Gender Based Analysis On April 1, 2009, Health Canada introduced the Sex and Gender Based Analysis (SGBA) Policy to respond to evidence that biological, economic and social differences between women and men contribute to differences in health risks, health service use, health system interaction and health outcomes (Health Canada, 2010, para. 7). The underlying premise of this approach is that sex and gender are fundamental influences on the identities and experiences of both women and men (Clow, Pederson, Haworth-Brockman, & Bernier, 2009, p. 157) and that sex and gender should be placed front and centre 12

13 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte in order to ascertain the gendered implications of research, policies and programs. Clow et al. (2009) also assert that SGBA recognizes the variations among women and among men, as well as between them, and that both the theory and practice of SGBA emphasize the intersections of multiple aspects of individual identity and experience. Arguably, however, SGBA is underpinned by a type of gender theorizing that highlights binary differences between men and women, with a strong focus on the needs and experiences of women. Consequently SGBA tools are not designed to ensure that the differences between different groups of women and men are examined or that different types of population groups are interrogated. Clow et al. (2009) claim that: From its roots as a white, middle-class urban women s movement, based largely in North America and Europe, sex and gender-based analysis has become more inclusive and expansive, embracing both the analysis of diversity and an understanding of global perspectives on the health and well-being of women and girls as well as for men and boys. (p. 158) However, the consequence of giving primacy to sex and/or gender differences, and of assuming the stable categories of male and female as a binary is to inhibit a full interrogation of the complexity of health experiences and needs. Not surprisingly then, the theoretical foundations of SGBA have been deemed inadequate for tackling the diversity of health inequities in research and policy (Canadian Research Institute for the Advancement of Women, 2006; Hankivsky, 2012; Hankivsky & Cormier, 2009; Wolf, 2011). 1 Health Impact Assessment Tools The World Health Organization has defined HIAs as a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population (1999, p. 4). Although HIAs have been subject to a variety of interpretations and applications, their general aim is to determine the potential negative or positive effects of policy in terms of increasing or reducing health inequities across different population groups in the move to create healthier societies (Scott- Samuel & O Keefe, 2007; Simpson, Harris, & Harris-Roxas, 2004). Most recently, Health Equity Impact Assessments (HEIAs) and their outgrowths namely Equity Focused Health Impact Assessment Frameworks (e.g., Harris-Roxas, Harris, Maxwell, Thornell, & Peters, 1 It is important to acknowledge that in the spring of 2012, Status of Women Canada introduced a new federal policy tool: GBA+ (Gender-Based Analysis Plus) a method for examining the intersection of sex and gender with other identity factors, such as age, education, language, geography, culture and income. It is expected that new approach will influence all federal departments including Health Canada. 13

14 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis 2011; Mahoney, Simpson, Harris, Aldrich, & Stewart Williams, 2004) have emerged in the literature and seek to more explicitly place equity at the forefront of policy impact analysis. The main difference between SGBAs and HIAs/HEIAs is that the latter are anchored within social determinants of health frameworks that recognize a plethora of structural and social factors that affect health and do not automatically give primacy to any one factor (e.g., gender) in their analysis. Social determinants frameworks have become increasingly popular in recent years within the field of health and policy for use in understanding and addressing health inequities i.e., avoidable, unnecessary and unjust differences in the health of diverse groups of people (Braveman, 2003; Evans, Whitehead, Diderichsen, Bhuiya, & Wirth, 2001). Various frameworks of social determinants have been suggested, both nationally (Mikkonen & Raphael, 2010; Public Health Agency of Canada, 2011) and internationally (Dahlgreen & Whitehead, 2006; WHO, 2007), all emphasizing similar factors and social conditions as the causes of health and illness. Within the Canadian health and policy fields, the most widely recognized social determinants of health framework is that of the Public Health Agency of Canada (2011), which lists the following determinants: Income and Social Status, Social Support Networks, Education and Literacy, Employment/working Conditions, Social Environments, Physical Environments, Personal Health practices and Coping Skills, Healthy Child Development, Biology and Genetic Endowment, Health Services, Gender, and Culture (Key Determinants section) Grounded in a social determinants of health framework, HIAs have been invaluable for underscoring the variety of factors that influence and shape health. For example, they have been recognized for their ability to promote equity, sustainability and healthy public policy; improve the quality of decision-making; promote social and environmental justice; encourage public participation in public policy; prioritize both quantitative and 14

15 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte qualitative evidence; make values explicit and open for discussion and debate; and bring attention to how policy in all sectors, including but not limited to health affects health (Scott-Samuel & O Keefe, 2007, p. 212). According to the National Collaborating Centre for Healthy Public Policy (2010) in Canada, HIAs are currently the most structured practices available to actors working in the area of healthy public policy. Not surprisingly, the appeal of HIAs and, in particular, HEIAs has grown over the last decade, especially in New Zealand (Ashton, 2007; Public Health Advisory Committee [PHAC], 2005), Australia (Harris, Harris-Roxas, Harris, & Kemp, 2007; Simpson, 2009), Canada (Haber, 2010; Handel, Ambtman, & Mohamed, 2010), and throughout much of the European Union (EU) (Harris et al., 2007; National Health Service, 2010; Welsh Health Impact Assessment Support Unit, 2004; see Birley, 2011 and Gunther, 2011 for important overviews). Work has also been done to determine the commonalities and differences of key HIA guides internationally to determine the plausibility of consensus guidelines in the field (Hebert, Wendel, Kennedy, & Dannenberg, 2012). At the same time, HIAs have also been critiqued for their lack of attention to policies outside of those directly affecting the internal operations of nation states (e.g., foreign policy) (Ingram, 2006). Others have noted that there is a lack of guidance to ensure that equity is fully integrated into HIAs (Harris-Roxas, Simpson, & Harris, 2004; Simpson, Mahoney, Harris, Aldrich, & Stewart-Williams, 2005). According to Scott-Samuel and O Keefe (2007) HIAs need to expand their focus on what actually determines health. They argue that, HIA can be pursued using a lens of increasing width that tracks the factors that have an impact on health (p. 215). From an intersectionality perspective, such critiques can be extended by also acknowledging the following five limitations that impede the potential of HIAs/HEIAs. First, there is no systematic integration of the fact (and extent) that conceptualization, prioritization, and evaluation of both desired and actual policy effects are largely shaped by the values, experiences and expertise of policy actors (McCaughey & Bruning, 2010; Overseas Development Institute, 2009; Sabatier, 2007). One positive exception is New South Wales Health Impact Assessment: A Practical Guide (Harris et al., 2007), where the scoping process of an HIA includes the formation of a steering committee with expertise surrounding the proposed topic, the potential population(s) affected, community involvement, public health evidence and research, negotiation skills, policy analysis, equity issues and the social determinants of health (p. 12). Nevertheless, policy actors and researchers conducting HIAs must be reflexive in order to help ensure clear and consistent recognition of the inherent biases in decision makers worldviews. 15

16 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis Second, while many HIAs recognize that policies and their lived effects cannot be separated from social, economic, cultural and historical factors that determine health, they fail to fully explicate the relationality of such factors and the ways in which they are connected. For example, grounded within social determinants of health frameworks, HIAs prioritize socioeconomic status (SES), along with a range of other inequities, such as gender, ethnicity, geographic location and ability (PHAC, 2005; Signal, Martin, Cram, & Robson, 2008; Simpson, 2009) without fully understanding how these interact or are coconstituted (Hankivsky & Christoffersen, 2008). Moreover, while HIAs do not ignore the contexts of people s lives, they typically view social locations like gender, race and class as homogenous, unconnected and static rather than as dynamic, intersectional and fluid (Manuel, 2006). This can lead to categorizing people as specific most-at-risk populations (MARPs) or target populations (Ministry of Health and Long-Term Care, 2011). Policies that are focused on at risk identities (e.g., women, Aboriginals) or behaviours (e.g., men who have sex with men (MSM), injection drug users (IDUs)), do not consistently addresses important within and between group differences and may eclipse or erase individual and group identities and social locations (Grace, 2012; Young & Meyer, 2005). Third, even though HIAs highlight structural causes of health inequities, they fall short in drawing together the complex operation and effects of processes of differentiation and systems of domination across different societal levels (e.g., macro, meso and micro) (Dhamoon & Hankivsky, 2011; Grace, 2011). It is clear that an analysis of policy processes and their effects must be contextualized within the broader multi-level relations of power in which these processes and effects are situated. Accordingly, both social locations and the processes of power that influence and determine them (e.g., patriarchy, capitalism, heterosexism, imperialism) including policy processes themselves need to be considered as important, interrelated structural determinants of social experience and health. To date, HIAs and HEIAs have failed to do this. Fourth, HIAs do not leave room for analyzing the effects of resistance and resilience on equity in the context of health policy. This undermines the ability of researchers and policy actors to understand that policies that label populations as inherently marginalized or vulnerable undermine the reality that there are in fact no pure victims or oppressors in society (Collins, 1990; Dhamoon & Hankivsky, 2011). The complexity of the human condition means that in all instances including in the context of health and healthy policy people have varying degrees of privilege and penalty. Importantly then, even from so-called marginalized spaces and locations, oppressive values, norms and practices can be questioned and challenged. For example, one principle mechanism of resistance from subordinated groups has been collective actions to destabilize dominant ideologies (Dhamoon, 2011). However, the focus of HIAs on categorical approaches 16

17 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte to social identities obscures similarities between population groups and their shared relationships to power. Such a focus prevents coalitional work as it reinforces differences and distinctions based upon specific categories. Finally, HIAs fail to consistently prioritize the voices and participation of people that may be intentionally or inadvertently affected by policy processes. Though community and stakeholder participation are acknowledged in some HIA frameworks (Kemm, 2007), particularly HEIAs (e.g., Haber, 2010; Harris et al., 2007), such participation is typically not considered central to policy analysis. Often the tendency for HIAs is to consult with representatives of particular categories of people in ways that a) appear very paternalistic or tokenistic (Kemm, 2007, p. 7), and b) obscure the diverse perspectives and needs of people within and across social categories/locations. These enumerated limitations demonstrate that, despite making important headway in bringing equity to the forefront of health policy analysis, HIAs require further advancement. As the following section elaborates, such shortcomings can be addressed by drawing on the paradigm of intersectionality, which has as its core aim to understand, analyze and respond to multiple, complex and interacting inequities. Intersectionality Rooted in a long and deep history of Black feminist writing, Indigenous feminism, third world feminism, and queer and postcolonial theory (Bunjun, 2010; Collins, 1990; Crenshaw, 1989, 1991; Van Herk, Smith, & Andrew, 2011), intersectionality has emerged as a widely respected, albeit variously defined research and policy paradigm (Hancock, 2007b). Nevertheless, there are a number of central tenets that capture the unique nature of this paradigm. These are: human lives cannot be reduced to single characteristics; human experiences cannot be accurately understood by prioritizing any one single factor or constellation of factors; social categories/locations, such as race /ethnicity, gender, class, sexuality and ability, are socially constructed, fluid and flexible; social locations are inseparable and shaped by interacting and mutually constituting social processes and structures, which, in turn, are shaped by power and influenced by both time and place; and the promotion of social justice and equity are paramount (Hankivsky, 2012; Hankivsky & Cormier, 2009). 17

18 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis Intersectionality is concerned with bringing about a conceptual shift in how researchers, civil society, public health professionals and policy actors understand social categories, their relationships and interactions. It requires a consideration of the complex relationship between mutually constituting factors of social location and structural disadvantage so as to more accurately map and conceptualize determinants of equity and inequity in and beyond health (Grace, 2010). Intersectionality encourages critical reflection that allows researchers and decisionmakers to move beyond the singular categories that are typically favoured (e.g. gender, race and class) in policy analysis to consider the complex relationships and interactions between the aforementioned trinity and other social locations and identities, such as Indigeneity, sexuality, gender expression, immigration status, age, ability and religion. This enables an examination of the simultaneous impact of and resistance to systems and structures of oppression and domination, such as racism, classism, sexism, ableism and heterosexism (Hankivsky & Cormier, 2009). Importantly, intersectionality is founded on what HIAs commonly overlook: reflexivity, relationality, processes of differentiation and accounting for resistance/resilience tenets outlined in more detail below. As Ferree (2009) explains elsewhere, intersectionality warns us of the risks of policies that, by privileging the treatment of some inequities and ignoring the fact that inequalities are often mutually constitutive, end up marginalizing some people, reproducing power mechanisms among groups, and failing to address the creation of categories that are at the root of the constitution of inequities. Applying intersectionality in the context of policy can thus be considered a political action, as it demonstrates a commitment to ameliorating inequitable relations of power that maintain inequity relations that often remain unquestioned in dominant policy approaches. Intersectionality and Policy Though the evidence base supporting the differential effects of policy across multiple axes of diversity is in its infancy, intersectionality-based analyses have been leading this line of inquiry (e.g., Bishwakarma, Hunt, & Zajicek, 2007; Bose, 2012; Collins, 1990; Crenshaw, 1991, 1989; Hancock, 2007a, 2007b, 2011; Hankivsky, 2011; Hankivsky & Cormier, 2011; Hankivsky et al., 2010; Iyer, Sen, & Östlin, 2008; Lombardo & Verloo, 2009; Manuel, 2006; Reid, Pederson, & Dupere, 2007; Schulz & Mullings, 2006; Varcoe, Hankivsky, & Morrow, 2007). For Lombardo and Agustin (2009) a good intersectional policy analysis has the following components: 18

19 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte explicitness and visibility of certain inequalities as well as the inclusiveness of a wide range of multiple inequality categories in the policy documents; the extent of articulation of intersectionality which implies both the mentioning of the intersecting categories and the way they are dealt with in the documents (e.g. as separate or mutually constitutive categories for examples); the appearance of lack of transformative approach to the issue of intersectionality; a structural understanding of power hierarchies and the dimensions of inequality, also in relation to addressing both individual and group dimensions; awareness/challenging of privileges and internal inequality biases in the policy documents; avoiding the potential stigmatization of people and groups at different points of intersection; and the consultation of civil society actors in the policy making process. (p. 4) However, only a handful of tools have been developed for applying intersectionality to public policy. For example, Bishwarkarma et al. (2007) have developed questions and criteria for an intersectional analysis in four stages of policy making, including agenda setting (problem structuring), policy formulation (alternatives and recommendations), policy implementation (monitoring) and policy assessment (evaluation). Meanwhile, Parken and Young (2007) have developed a multi-strand model that seeks to move beyond silo approaches to policy by focusing on a policy field and then showing the steps involved in capturing relationships between different forms of inequity as well as resulting individual and group disadvantages. Their multi-strand model has four distinct stages: mapping, visioning, road testing, and monitoring and evaluation. The model involves a range of expertise in the areas of policy, equality, and human rights, and it is intended to engage with all relevant stakeholders. It is based upon the collection, collation, analysis and synthesis of equality evidence for all equality strands and human rights and those outside of strands (Parken & Young, 2007, p. 50; Parken, 2010). Finally Rönnblom (2008) has developed the concept of spatial dimensions to advance the contextualization of intersectionality-informed analysis so that different and intersecting power relations in policy can be better understood. Emerging methods for operationalizing intersectionality in policy acknowledge the inherent difficulties of this work. The incremental and reductionist nature of policy and the short-term horizons of its making are often incompatible with the demands of an intersectionality-based analysis. All the efforts to date also signal the highly exploratory nature of the work being undertaken. While critical evaluations of such nascent approaches have been performed elsewhere (see for example Hankivsky & Cormier, 2011), existing tools represent important foundations on which to build more effective and concrete methodological approaches to intersectionality-informed policy. As Manual 19

20 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis (2006) puts it, intersectionality theory represents an incredibly useful analytical lens for policy scholars who wish to strengthen the explanatory power of policy models that evaluate policy impacts and outcomes (p. 175). A pressing and ongoing challenge in advancing this line of work is the further development of explicit and user-friendly methods than can more effectively translate intersectionality theory into practical approaches that can be used by decision-makers and policy researchers. There is widespread acknowledgment that the meaning and essence of intersectionality for contemporary policy debates needs further clarification, that more concrete policy guidance is required to assist in dealing with the multifaceted ways in which human experience is shaped, and that any effective and transformative intersectionality-informed methods and frameworks must capture the complexities, nuance and reality of policy processes, decisions and outcomes. It is also important that efforts are made to build on and link to well-known equity informed policy tools namely HIAs to increase the chances of uptake and widespread application in public policy discourses. The Goal of this Collection While the purpose of this chapter is to provide the policy context and rationale for an intersectionality-informed policy analysis, the remainder of this collection is focused on the how-to of taking on the messy policy work of capturing complexity and variation in human lives. The Intersectionality-Based Policy Analysis (IBPA) Framework and related case studies presented in this collection were developed and refined through an iterative, participatory process ( ). The final Framework reflects not only the efforts of the listed authors, but comments and feedback received from emerging and established scholars in the field at roundtable discussions and learning institutes. Based on a series of meetings and peer feedback, as well as on critical reflection into current gaps and trends in equity-promoting public policy analysis, the group collaboratively devised a draft IBPA Framework from which to guide the development of our case studies. This draft was further revised near the completion of the case studies, as the intention of the group was to engage in an ongoing process of refinement to ensure that the IBPA is a usable and practical guide for policy analysis. The following chapter Intersectionality-Based Policy Analysis outlines our framework for an IBPA, including key principles and guiding questions to inform policy analysis. 20

21 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte The remainder of the collection consists of seven policy case examples, grounded in each respective author s program of research. Each case study applies the IBPA Framework to a specific health related issue. The focus of these case studies is on British Columbia, Canada, but the discussion of the policy issues is pan-canadian, and potentially applicable in other geopolitical contexts. In applying IBPA to a broad spectrum of issues using a variety of methods, the authors illustrate the inherent flexibility of IBPA for a range of policy applications. At the same time, each case study is grounded in key intersectionality principles to ensure IBPA s transformative effects on how policy problems and issues are understood and responded to. Collectively the case studies demonstrate concretely and persuasively the added value of engaging with intersectionality for analyzing social and health inequities. The first two case studies focus on policy issues typically understood as highly gendered phenomena. Both authors, however, draw on IBPA to illustrate the importance of multiple social locations and structures of power, including but not limited to gender, that influence the availability and delivery of health services. To begin, Rudrum examines current maternity care policy, revealing inequities in access to high-quality appropriate care for differently situated women across geography, ethnicity and socioeconomic status. In the process this author challenges the idea that there are fixed norms or standards in the care that women require in pregnancy and childbirth. Next, Giesbrecht focuses on palliative care policy, revealing the current inequities in access to services and supports, and demonstrating the extent to which choices at the end of life by those who need and provide care are inextricably linked to interactions between socioeconomic status, service provision, cultural discourses, and emotional, spiritual and relational factors infused with physical and social aspects of place. Three of the case studies specifically touch on issues related to Aboriginal health. Hunting s examination of Fetal Alcohol Spectrum Disorder (FASD) shows why Aboriginal populations continue to experience health inequities in relation to current policies. She argues that a sole focus on women as a category, a narrow conception of risk, and a lack of attention to intersecting processes of oppression within FASD policy discourse undermine the development of IBPA-informed policy processes and reforms that can more effectively address the diverse experiences, needs and perspectives of those affected by substance use. Second, in reviewing policy processes of the Kelowna Accord a national Aboriginal health policy initiative that was developed but never implemented Fridkin demonstrates how IBPA can be applied to issues in Aboriginal health policy to promote the inclusion of Aboriginal peoples in policy making and contribute to agendas of decolonization. Fridkin illustrates how IBPA can be used to analyze not just policies themselves, but policy processes, thus highlighting the potential of IBPA to expand what is typically 21

22 Introduction: Why Intersectionality Matters for Health Equity and Policy Analysis constituted as policy analysis. Third, using an IBPA lens, Clark shows that even policies that forefront Aboriginal needs fall short because they often fail to consider the multiple and intersecting layers of Indigenous identity, such as age, rurality, gender-expression and experiences of trauma, including interactions with multiple policy systems. Clark s contribution is also important in that she draws significant parallels between intersectionality and Indigenous ways of knowing, while raising critical questions about the relationship between IBPA and Indigenous epistemology. The final two case studies in the collection tackle various issues relating to HIV. First, Grace draws on IBPA to advance understandings of complex issues facing sexual minority populations by considering both current understandings and testing technologies surrounding HIV and the criminalization of HIV non-disclosure. He makes a persuasive argument for using IBPA to advance an equity-focused understanding of the problem of HIV transmission that places front and centre the structural drivers that produce differential vulnerabilities among affected populations. Lastly, Ferlatte uses an intersectionality lens to evaluate HIV prevention funding for gay men. The examination includes consideration of discourses around HIV, funding application processes and funding decision outcomes. His analysis highlights the structural barriers involved in securing support for HIV prevention. Importantly, Ferlatte discusses possible alliances with other groups, such as sex workers, to work for policy change rooted in understandings of the power dynamics that currently shape the HIV funding system. 22

23 Olena Hankivsky, Daniel Grace, Gemma Hunting, and Olivier Ferlatte Conclusion This chapter has demonstrated the importance of utilizing intersectionality when addressing matters of policy and equity so as to improve upon existing tools. We have positioned intersectionality as a research and policy paradigm that can make visible complex issues of inequity obfuscated by previous frameworks. In the remainder of the collection, we present the Intersectionality-Based Policy (IBPA) Framework and case studies that apply IBPA. The case studies model uses of IBPA with the goal of bringing issues of equity to the fore and ultimately inspiring others to use this approach in their own policy work.the IBPA Framework is intended to be a living document that will change and evolve over time as a range of end users pilot test and provide feedback on how the Framework can be improved and made more effective and precise. The intended audiences for this collection include analysts working in a range of policy sectors but especially those working within health and health related policy sectors, community organizations engaged in healthy policy advocacy and development, and health researchers seeking improved methods for understanding the health and social effects of policy. The collection is thus intended to contribute to emerging literature in the field by expanding current paradigms of policy analysis and allowing policy actors to see themselves as critical players in the development, implementation and evaluation of policy. 23

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